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It is well appreciated today that sudden cardiac death (SCD) occurs in patients with floppy mitral valve (FMV)/mitral valve prolapse (MVP) without significant mitral regurgitation . Data from studies most likely represent a heterogeneous population and probably underestimate the true incidence of SCD in this group of patients. SCD in patients with FMV/MVP occurs mostly in young individuals without comorbidities. Over the last decade, the phenotypic expression of patients with FMV/MVP at risk for SCD (bileaflet prolapse, redundant mitral leaflets, symptomatic young women) have been defined, possible pathophysiologic mechanisms leading to SCD have been proposed, and appropriate steps to prevent the catastrophic event, though in evolution, have been suggested. In this review, state-of-the-art knowledge related to SCD in patients with FMV/MVP is summarized.

OBJECTIVES Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery (MVR±TVR). Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer. METHODS We analyzed the largest registry of MVR±TVR patients (MMIR) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015–2021, 7,513 consecutive patients underwent mini-MVR±TVR in 17 international Heart-Valve-Centres. Data were collected according to MVARC definitions and 6878 patients with one cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times. RESULTS Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (IQR: 0.80–2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional TVR and 19% AF-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR : 107–173) and 85 min (IQR : 64–111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all p CONCLUSIONS Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes.

Objective With the popularization of catheter-based mitral valve procedures, evaluating risk-specific differentiated clinical outcomes after contemporary mitral valve surgery is crucial. In this study, we assessed the operative results of minimally invasive mitral valve operations across different patient risk profiles and evaluated the value of EuroSCORE II predicted risk of mortality model for risk prediction, in the large cohort of Mini-Mitral International Registry (MMIR). Methods The MMIR database was used to analyze mini-mitral operations between 2015 and 2021. Patients were categorized as low- ( Results A total of 6541 patients were included in the analysis. Of those, 5546 (84.8%) were classified as low risk, 615 (9.4%) as intermediate risk, 191 (2.9%) as high risk and 189 (2.9%) as extreme risk. Overall operative mortality and stroke rates were 1.7% and 1.4%, respectively, and were significantly associated with patient’s risk. The observed mortality was significantly lower than expected -according to the EuroSCORE II- in all risk categories (O: E ratio < 1). Conclusions The present study provides an international contemporary benchmark for operative outcomes after minimally invasive mitral surgery. Operative results were excellent in low-, intermediate- and high risk patients, but were less satisfactory in extreme risk. The EuroSCORE II model overestimated the in-hospital mortality. We believe findings from the MMIR may assist surgeons and cardiologists in clinical decision-making and treatment allocation for patients with mitral valve disease.

Surgical atrial fibrillation (AF) ablation is a valid option in cases of concomitant cardiac surgery. Electroanatomical mapping before and after the procedure can assess the substrate and verify durable lesion formation. It is likely that a routine combined cardiosurgical and electrophysiological approach may yield the greatest benefit for such patients.

Mitral commissural prolapse or flail, either isolated or combined with more extensive degenerative valve disease imposes several challenges both on its diagnosis and management whilst being a risk factor for valve reoperation after mitral valve repair. Accurate identification of the prolapsing segment is often not feasible with transthoracic 2D echocardiography, with transesophageal 3D imaging then required for correct diagnosis and surgical planning. Various surgical techniques employed alone or in combination, have yielded good results in the repair of commissural prolapse. Herein, we analyze the specific characteristics of commissural disease focusing our attention on 2D and 3D echocardiographic findings and we briefly comment on techniques employed for surgical correction of the disease.

cholars debate the issue of how to improve Business Ethics Education (BEE) such that it has an impact on managerial practice. We contribute to this discussion by proposing a pedagogy that we denominate embodied phronesis. We developed the pedagogy and applied it for over five years at an Australian business school. Embodied phronesis is based on experiential learning and cultivates students’ ethical-moral capabilities by integrating normative aspects (a reflection on ethical principles informing decisions); behavioural factors (the role of emotions and pre-conscious reactions in shaping ethical behaviour); and social determinants (a consideration of power relations enabling and constraining ethical practice in organizations). To understand the impact of this pedagogy, we analyse reflective diaries written by postgraduate business students who completed a course designed according to these principles. We find that embodied phronesis enables students to shift from a technical, values-free conception of managerial action to a view of management as ethical and moral practice. Our pedagogy allows students to deal with the complexities inherent in business ethics while simultaneously illustrating that there are not simple answers to the problem ‘how to be ethical in a business context’.

Secondary (also known as functional) mitral regurgitation (MR) has increased substantially over the last several decades due to an increase in the prevalence of dilated cardiomyopathy (ischemic and non-ischemic). Mortality and morbidity in patients with dilated cardiomyopathy is much greater when associated with MR as compared to without MR. MR will result in further left ventricular (LV) volume overload, LV dilation, and pupillary muscle displacement resulting in deterioration of the severity of MR leading to a vicious cycle. Optimization of heart failure medical therapy, and cardiac resynchronization therapy for those that qualify, can improve severity of MR; however, significant MR will persist in certain patients. Transcatheter mitral valve repair to treat significant MR using the MitraClip (Abbott, Menlo Park, California), which grasps and coapts the posterior and anterior mitral valve leaflets, in appropriately selected patients with dilated cardiomyopathy and secondary MR has been shown to improve quality of life and prolong survival.

Characterized by strategic importance, dynamic complexity, adaptability and extensive impacts, megaprojects are inherently vulnerable to crises. Using structural equation modeling, this paper proposes and tests two new theoretical constructs that could be useful for understanding management of megaproject crises. The study proposes crisis orientation and crisis awareness as prominent antecedents to better anticipation of megaproject crises. Crisis orientation is a second-order construct that builds upon five independent first-order dimensions: lack of project management skills; clash of interest; lack of responsibility; red tape and centralization; and lack of ability to forecast. In addition, the paper suggests a first-order construct (crisis awareness) affects predictable risks concern. The survey results of 168 individuals in Chinese megaprojects suggest that higher crisis orientation and crisis awareness support higher predictable risks concern. The findings imply that strategies aimed at enhancing crisis orientation and crisis awareness would promote early detection and mitigation of future crises.

Floppy mitral valve/mitral valve prolapse (FMV/MVP) is a common valvular abnormality affecting 2% to 3% of the general population. It occurs in a heterogeneous group of patients with varying and age dependent expressions. FMV/MVP can be familial or sporadic, isolated (called non-syndromic) or as a part of a well-defined syndrome of heritable connective tissue disorders or other diseases. A wide range of phenotypic expression exists ranging from asymptomatic to non-specific symptoms related to neuroendocrine or autonomic nervous system functional abnormalities, varying degrees of mitral regurgitation that may require interventional therapy, heart failure, infective endocarditis, cardiac arrhythmias and/or sudden cardiac death. FMV/MVP is predominantly considered a heritable disorder with clinical manifestations not present at birth, but appearing later in life. Though a variant gene may initiate the development of FMV/MVP, precise phenotypic expression may be related to multiple other molecular, genetic and epigenetic factors that modify the final expression of the disease. A better understanding of these mechanisms will help to better define the natural history of the disease, inhibit disease progression and even prevent the phenotypic expression of FMV/MVP.

Design thinking has made huge inroads in organizations today and has been widely popularized as one of the most effective approaches to complex problem solving. However, the prescriptive models to design thinking that are now widely used by “nondesigners” in the business world are criticized for their detachment from users, poor execution, and tendency to converge on safe solutions. This article examines the efficacy of using crowdsourcing as an underpinning technology for executing design thinking by nondesigners to alleviate these issues. It advances a generative model of complex problem solving with theoretical as well as practical implications.

OBJECTIVES Artificial chordae tendineae are widely used for surgical repair in patients with mitral regurgitation due to floppy mitral valve/mitral valve prolapse. Expanded polytetrafluoroethylene has been used to construct these artificial chordae; however, the determination of the optimal length of the chordae prior to surgery has been an issue. For this reason, such a method was developed and the results of its use are presented. METHODS Forty-seven consecutive patients with significant mitral regurgitation due to floppy mitral valve/mitral valve prolapse who underwent totally endoscopic mitral valve surgery were studied. The chordae length was predetermined using transoesophageal echocardiography. The length between the top of the fibrous body of the papillary muscle and the coaptation line of the 2 leaflets of the mitral valve was measured and used to define the length of the chordae to be used for repair. Then under stereoscopic vision, a total endoscopic mitral valve repair was performed. RESULTS The predicted mean length of chordal loops was 19.76 ± 0.71 mm (median 20, range 16–28) and the actual mean length of chordal loops used was 19.68 ± 0.74 mm (median 20, range 16–26) demonstrating an excellent correlation between the two (r = 0.959). The mean number of chordae loops used per patient was 5.12 ± 0.62 (median 4, range 2–12). All patients at the time of discharge had no or trivial mitral regurgitation on transoesophageal echocardiography. CONCLUSIONS The chordae length used for mitral valve repair can be determined prior to surgery using transoesophageal echocardiography with a high degree of accuracy. Further, total endoscopic repair in this group of patients provides excellent results. For these reasons, it is expected that this method will replace most traditional approaches to cardiac surgeries in the years to come.

This is an introduction to the special issue of California Management Review on Design Thinking (DT). This special issue joins the growing body of work exploring the idea of DT and whether DT makes a difference in terms enhancing or augmenting the impact of technology—and, as a result, innovation—in a positive way. We have chosen an interesting, relevant, and useful array of papers that provide different approaches, views, and interpretations of applied design thinking. These articles provide both management and scholarly readers with insights in how DT is used, as well as its impact and usefulness in a variety of contexts.

This document describes the ported software of the EuroEXA applications to the single CRDB testbed and it discusses the experiences extracted from porting and optimization activities that should be actively taken into account in future redesign and optimization. This document accompanies the ported application software, found in the EuroEXA private repository (https://github.com/euroexa). In particular, this document describes the status of the software for each of the EuroEXA applications, sketches the redesign and optimization strategy for each application, discusses issues and difficulties faced during the porting activities and the relative lesson learned. A few preliminary evaluation results have been presented, however the full evaluation will be discussed in deliverable 2.8.